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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804132
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:13:16 PM

Document Has Been Signed on 05/15/2024 03:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:IMAGINE AT UNIONFACILITY NUMBER:
486804132
ADMINISTRATOR/
DIRECTOR:		PUNZALAN, VIRGINAFACILITY TYPE:
735
ADDRESS:830 UNION AVETELEPHONE:
(818) 642-3943
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:36 PM
MET WITH:Virginia Punzalan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced 1-Year Annual Inspection at Imagine at Union. LPA met with Administrator Virginia Punzalan. Patricia Bucal, House Manager was also present. The facility has a fire clearance approval for a total of 4 ambulatory only residents. Facility will operate with 24 hour staffing and Licensee will ensure sufficient staffing at all times. There was an ample supply of perishable and nonperishable foods, as required per Title 22. Hot water was within 105-120 F. Facility was homelike with plenty of space for dining and socializing.

During today’s visit LPA observed the following items:
· Lockable separate cabinets for medication, toxins, and knives.
· All exits were unobstructed
· 7 smoke detectors and 1 carbon monoxide detector were tested and observed operational
· Supply of linens, paper products, and hygiene supplies available
· Fire Extinguisher charged and serviced 01/04/2024
· Required furnishings in 4 of 4 bedrooms
· Administrator Certification; Required postings displayed

4 out of 4 client files were inspected and found to be complete.
4 out of 4 staff files were inspected and found to be complete. All staff had valid First Aid/CPR training.
Exit interview with Administrator.

No deficiencies were found at the time of inspection. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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